Overview of Anxiety Disorders in Children and Teens

As I discuss, in the newly released second edition of 10 Days to a Less Defiant Child, which was cited in the Wall Street Journal, anxiety underlies a high percentage of behavioral issues and struggles in children and teens. Below are key points on the topic of anxiety in children and teens from a wonderful presentation I recently attended. The sources of this information are provided at the end of this post.

Lifetime prevalence of anxiety: twenty-five percent of 13 to 18 year olds have mild to moderate anxiety. Lifetime prevalence of severe anxiety disorder is 5.9 percent.  Girls are more likely than boys to be diagnosed with an anxiety disorder. Median age of onset is 11 years old. Anxiety is among the earliest of developing pathologies. Anxiety in children and teens often overlaps with depression.

Symptoms: Muscle tension, physical weakness, poor memory, sweaty hands, confusion, constant worry, shortness of breath, palpations, upset stomach, and poor concentration.

Reasons for increased anxiety: Post 911, parental pressures, terrorism, media fears, social media pressures (e.g., kids viewing pictures of being left out of parties), and perceived threats.

Causes of anxiety:  Combination of genetic, environmental, psychological, and developmental factors, overscheduled children, and poor sleep.

Brain regions associated with anxiety: Thalamus, Hypothalamus, Hippocampus, Amygdala, Basal Ganglia, Prefrontal Cortex, Orbitofrontal Cortex, and Anterior Cingulate Gyrus

Child and Teen Problems Resulting from Anxiety: Poor school performance, problems with peers, substance use, psychosomatic illnesses, low self-esteem, and psychopathology in adulthood.

Personality traits (assets or liability or both) Responsible, perfectionism, difficulty relaxing, worrying, likes to please, avoids conflict, low assertiveness.

Anxiety disorders: Generalized Anxiety Disorder, Separation Anxiety, Selective Mutism, Panic Disorder, Agoraphobia, Social Anxiety, Specific Phobias, Obsessive Compulsive Disorder, Acute Stress Disorder, and Anxiety due to a medical condition.

Strategies to Help Children and Teens with Anxiety

Cognitive Behavioral Therapy (CBT): Growing body of evidence over twenty years supports efficacy and effectiveness of CBT with children and teens. CBT more effective than no treatment, placebo, or alternative treatment and multiple trials have been conducted. CBT was noted to be efficacious treatment for childhood anxiety according to the American Psychological Association Task Force on Psychological Interventions.  

Several other therapy modalities can work well too, such as mindfulness-based treatments like ACT (Acceptance and Commitment Therapy), and Dialectical Behavior Therapy (DBT).

Identifyin sources of anxiety about school: Common worries: school performance, parental pressures, appearance, social acceptance, friend pressures, and bullying.

Psychoeducation is very important: Teaching Children and Teens about Anxiety:

Teach youth connection between the physical, cognitive, and behavioral signs.
Use the “false alarm” metaphor as it relates to fight or flight.
Normalize reasonable fear/anxiety.
Teach recognition of somatic responses.
Use role plays, you tube clips. biblioherapy, etc.

Cognitive Behavioral Therapy: Key Strategies and Points

Identify positive thoughts; “This challenge can be overcome.” or “I will be

Identify negative self-talk recognize and challenge the child’s misinterpretations (one setback does not make for a total failure). Help child recognize other views of situation exist.

Goal is not to overload with positive self-talk but to reduce negative self-talk.

Use positive affirmations: “I trust that everything will be okay if I give a good effort.”

Teach mindfulness: “Witnessing” involves labeling feelings without judgement: “It’s a thought not a fact”, that’s my feeling, now what are my choices”

Use the Miracle Question: Generates solution talk and focus. If a miracle happens tonight while you are sleeping so you won’t know what will happen until you wake up tomorrow morning. What will be different what will you notice and how will you know you will have changed?

Write a letter from the future: Write a letter from your future self to your current self include what you learned to help you get there.

Play the Part: Show what a relaxed confident kid looks like.

Use the Floating Technique (Claire Weekes, M.D.’s model: Face, Accept, Float, and Let Time Pass). Floating builds on acceptance and involves, moving through sensations, of anxiety without offering tense resistance, as one would when floating on gently, undulating water.

Reframe the harmless: Ask, “What is the worst thing that can happen?”

Externalize the worry:  Using words or acting out feelings to express feelings.

Prescribe the symptom: Children and teens can gain a sense of control when they are asked to deliberately think or do what they want to avoid.

OCD fact: Most children diagnosed with OCD are diagnosed around age 10. Boys are likely to develop OCD before puberty and girls to develop it during adolescence.

The CBT intervention that works best with OCD is exposure and response prevention. Exposure reduces anxiety, minimizing avoidance preventing rituals

For Post-Traumatic Stress Disorder in children, there are three responses to trauma that children often experience:

            1) Re-experiencing the trauma through repetitive play and setbacks.

            2) Avoidance of stimuli associated with trauma, which can lead to further anxiety.

            3) Persistent symptoms from trauma that increases arousal and interferes with school functioning.

Note: Pharmacologic treatments may be used with psychotherapeutic approaches

                                    Resources and Sources:

Anxiety Disorders Association of America

American Psychological Association

Bernstein, Jeffrey, 2015, Ten Days to a Less Defiant Child (Second Edition), Perseus Publishing

When My Worries Get Too Big (for elementary age), 2013, Kari Dunn Buron, AAPC Publishing

Credit to the source: The information shared in this post is a selected summary of a PESI presentation by Janet K. Kirsh, Ph.D. 

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